Hospitals improve patient outcomes with life-saving checklists

Intensive care is literally a life or death situation for many patients. The stark reality is that at any point, care providers have been as likely to harm patients as they have been to heal them.

Or so the case used to be.

In 2001, a critical-care specialist at Johns Hopkins Hospital named Peter Pronovost, attempted to lessen this statistic by creating a checklist to tackle one common problem in the I.C.U. On a sheet of paper he plotted out steps to take in order to avoid infections when inserting a line into a patient.

Today, variations of that checklist are used by two area hospitals for the operation of anesthesia machines and to prevent both bloodstream infections and diseases acquired through ventilator insertion, as well as to quickly diagnose and treat sepsis infections. Both hospitals practice according to approved infection control plans based on the Center for Disease Control and the Association for Professionals in Infection Control.

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While neither hospital would disclose infection rates for the past year because they are currently protected under peer review statutes, both Charlevoix Area Hospital and Northern Michigan Regional Hospital are working with the Michigan Hospital Association to develop standardized methods for comparison which will soon be made available to the public.

"Obviously, we want to make sure that any anesthetic delivered is the safest possible, therefore, anything we can do to allow for this is worth any minor inconvenience it may cause," said Ken Forrester, director of anesthesia services at Charlevoix Area Hospital. "The checklist also allows for more rapid determination of what may be a malfunction of a monitor and not the patient having an adverse reaction to the anesthetic since we have already gone through all the equipment for proper function."

Although recommended guidelines were released in the spring of 1994 by the Anesthesia Patient Safety Foundation, anesthesia providers have had checklists for the operation of anesthesia machines since 1993.

"The checklist made sense since anesthesia is in some respects like flying an airplane and the equipment needed to be checked for proper function prior to takeoff," Forrester said. "The checklist verifies the proper functioning, prior to use, of the anesthesia machine and all pieces of equipment used to monitor our patient's condition during the delivery of any anesthetic."

Forrester said that anesthesiologists realized years ago that something as simple as a checklist could improve patient outcomes. When he was in anesthesia school 25 years ago, the mortality associated with anesthesia was one per 100,000 anesthetics. Today the incidence of mortality related to anesthesia is one per 250,000-300,000.

"Some of that decrease in mortality is related to medication and monitoring capabilities but changes in the way we gave anesthesia occurred because we were forced to make improvements in safety features because of the checklist," he said. "There is a big difference in testing a new medication on unsuspecting patients versus adding a checklist that exposes 'shortcuts' or one that ensures that best practices are maintained."

He also feels that these simple quality improvement measures, and that's what he said they should be classified as, could spread nationwide because of their success.

"I have trained at both Detroit Receiving and Sinai-Grace Hospitals and am absolutely amazed at the results of this simple checklist," Forrester said. "Twenty-five years ago, Detroit Receiving had a resistant 'bug' in their I.C.U. that they had a very difficult time eliminating. To get these type of results with their invasive line placement is fantastic."

These results are just what motivate the critical care team at Northern Michigan Regional Hospital (NMRH). While it's far from obvious to some that something as simple as a checklist could be of much help in medical care, the critical care team said that because of the checklist, thinking at the hospital has changed as far as infections go.

"There should be no infections," said Gretchen Schrage, the hospital's manager for performance improvement. "As a result of one of the checklists, we have virtually eliminated catheter bloodstream infections."

The checklists provide two main benefits. First, they help with memory recall, especially with mundane matters that are easily overlooked in patients undergoing more drastic events. A second effect is to make explicit the minimum, expected steps in complex processes. And if doctors don't follow every step on a checklist, nurses have backup from the hospital's administration to intervene.

Duane Griffin, D.O., a pulminologist at NMRH said that the checklists provide a specific list so that you have all of your bases covered.

"Without the checklist, it's easy to think that someone else may have completed tasks," he said.